Techniques and Complications of Anesthesia in Pediatric Radiotherapy: A Retrospective Cohort Study

BACKGROUND

Anesthesia during pediatric external beam radiation therapy poses a challenge, as radiotherapy rooms are not designed for the administration of anesthesia.

AIMS

We conducted a retrospective cohort study of children who underwent radiation therapy to describe the anesthetic approach and assess anesthetic-related complications.

MATERIALS AND METHODS

Data of all, who underwent radiation therapy under general anesthesia between November 2019 and January 2021, were recorded. Data were obtained from medical records, including demographic characteristics and information, regarding the anesthetic procedure and its associated complications. We describe our protocols for preoperative assessment, anesthetic procedures, and postanesthetic discharge evaluation.

RESULTS

Over the reporting period, 739 sessions of general anesthesia were performed. The mean number of radiation therapy rounds per patient was 23.5 sessions. Anesthetic induction was accomplished by sevoflurane inhalation in 639 sessions (86.4%) and intravenous propofol in the remaining 13.6%. General anesthesia was maintained with sevoflurane in all cases. Anesthesia-related complications occurred in 118 sessions (15.7%). The most frequent was nausea in 48 (6.4%) cases, followed by hypotension in 38 (5.1%). Airway-related complications occurred at a low frequency (2.3%), and all were resolved successfully with positive pressure ventilation. No patient hospitalizations were required because of any anesthetic complications.

CONCLUSIONS

Inhalation anesthesia is reliable and safe for pediatric patients undergoing radiation therapy.

An Interactive Virtual Reality Tour for Adolescents Receiving Proton Radiation Therapy: Proof-of-Concept Study

BACKGROUND

Child life therapists provide patient education for children undergoing radiation therapy to assist in coping with and understanding their treatment.

OBJECTIVE

This proof-of-concept study aimed to determine the feasibility of incorporating a 360-degree video tour via a virtual reality system for children scheduled to receive radiation therapy. The secondary objective was to qualitatively describe each subject's virtual reality experience.

METHODS

Children aged ≥13 years scheduled to receive proton radiation therapy were included in the study. Subjects watched the 360-degree video of the radiation therapy facility in an immersive virtual reality environment with a child life therapist experienced in coaching children receiving radiation therapy and completed a survey after the tour.

RESULTS

Eight subjects consented to participate in the study, and six subjects completed the 360-degree video tour and survey. All the enrolled patients completed the tour successfully. Two subjects did not complete the survey. Two subjects requested to pause the tour to ask questions about the facility. Five subjects said the tour was helpful preparation before undergoing proton radiation therapy. Subjects stated that the tour was helpful because "it showed [them] what's to come" and was helpful to see "what it's like to lay in the machine." One subject said, "it made me feel less nervous." Six subjects stated that they would like to see this type of tour available for other areas of the hospital, such as diagnostic imaging rooms. None of the subjects experienced nausea or vomiting.

CONCLUSIONS

The 360-degree video tour allowed patients to explore the treatment facility in a comfortable environment. Participants felt that the tour was beneficial and would appreciate seeing other parts of the hospital in this manner.

Propofol-based balanced anesthesia is safer in pediatric radiotherapy

Backround and purpose

To investigate the incidence of complications related to propofol-based anesthesia and the factors associated with complications in children with radiotherapy.

Materials and methods

Patients who underwent anesthesia for external beam radiotherapy between May 2013 and November 2017 were included in the study. We assessed the age/weight, sex, oncologic diagnosis, type of radiotherapy procedure, duration of anesthesia, applied agents, and complications related to anesthesia. Complications were evaluated between group I (only propofol group) and group II (propofol plus adjuvant drugs) as respiratory and cardiac.

Results

In 130 patients, sedation was given for 1376 radiotherapy procedures. Of these, 1274 (1140 radiation treatment sessions and 134 computed tomography simulations) in 126 patients were propofol-based and were included in the analysis. Although respiratory complications are the most common in both groups, there were no episodes of laryngospasm, broncospasm, and no use of advanced airway intervention. The rate of complication was significantly higher in only propofol anesthesia group than in patients treated with propofol plus adjuvant drugs. In the multivariate analysis, we found three factors that were significantly associated with the risk of complications: total dose of propofol (mg/kg) (p < 0.001), anesthesia with propofol alone (as compared to propofol plus adjunct agents) (p = 0.001), and diagnosis of neuroblastoma (as compared to other diagnosis) (p = 0.043).

Conclusion

Propofol-based anesthesia is preferred in order to minimize the rate of complications in radiotherapy anesthesia applications. The use of non-opioid adjuvants in combination with propofol to achieve a balanced anesthesia will also reduce the complications that may be encountered.

Anesthesia complications of pediatric radiation therapy

PURPOSE

Complications of anesthesia for pediatric radiation therapy are imperative for both radiation oncologists and anesthesiologists to clinically assess and manage. We performed the first systematic review to date addressing this important issue.

METHODS

A systematic search of PubMed and EMBASE was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were not restricted based on publication date. Nine original investigations were identified, analyzed, and collated for this report.

RESULTS

General anesthesia has proven superior to conscious sedation with regard to maintaining satisfactory procedural sedation while maintaining low respiratory and cardiovascular complication rates. Although agents such as ketamine (complication rates approaching 23%-24%) have been used in the past, other agents such as propofol and volatile anesthetics have lower complication rates because of improved drug side effect profiles (0.01%-3.5%). Most common complications are respiratory-based (eg, airway obstruction, broncho/laryngospasm, desaturation, apnea), followed by those that are cardiovascular-based (eg, tachy/bradycardia, arrhythmias, hypotension) and nausea/vomiting. Though procedure duration and anesthetic dose can be associated with higher complication risks, prior or concurrent chemotherapy does not confer added risks other than neutropenia-related sepsis. Other potential complications include those with vascular access devices, observed in up to 20% to 25%, with peripherally inserted central catheters having the highest rates of vascular complications and port catheters the lowest.

CONCLUSIONS

Rates of anesthetic complications encountered in pediatric radiation therapy are similar, if not lower, than rates reported in controlled operating room settings, implying that anesthesia for pediatric radiation therapy is safe, with low complication rates periprocedurally. Propofol infusion and oxygen delivery via nasal cannula offer the lowest immediate anesthetic complication rates and are hence most recommended for use. Though the long-term neurocognitive consequences of multiple anesthetics in pediatric patients have yet to be clearly defined, health care providers should be cognizant of the potentially serious implications.

Non-invasive anesthesia for children undergoing proton radiation therapy

BACKGROUND

Proton therapy is a newer modality of radiotherapy during which anesthesiologists face specific challenges related to the setup and duration of treatment sessions.

PURPOSE

Describe our anesthesia practice for children treated in a standalone proton therapy center, and report on complications encountered during anesthesia.

MATERIALS AND METHODS

A retrospective review of anesthetic records for patients ⩽18years of age treated with proton therapy at our institution between January 2006 and April 2013 was performed.

RESULTS

A total of 9328 anesthetics were administered to 340 children with a median age of 3.6years (range, 0.4-14.2). The median daily anesthesia time was 47min (range, 15-79). The average time between start of anesthesia to the start of radiotherapy was 7.2min (range, 1-83min). All patients received Total Intravenous Anesthesia (TIVA) with spontaneous ventilation, with 96.7% receiving supplemental oxygen by non-invasive methods. None required daily endotracheal intubation. Two episodes of bradycardia, and one episode each of; seizure, laryngospasm and bronchospasm were identified for a cumulative incidence of 0.05%.

CONCLUSIONS

In this large series of children undergoing proton therapy at a freestanding center, TIVA without daily endotracheal intubation provided a safe, efficient, and less invasive option of anesthetic care.

Propofol depresses the cytotoxicity of X-ray irradiation through inhibition of gap junctions

BACKGROUND

General anesthetics (e.g., propofol) influence the therapeutic activity of intraoperative radiotherapy but the mechanism of the effects is largely unknown. It has been reported that propofol inhibits gap junction (GJ) function briefly, and a functional GJ enhances the efficacy of radiotherapy in some cancer cells. Yet the mechanisms underlying the inhibition of GJ function by propofol and the influence of propofol on therapeutic activity of intraoperative radiotherapy are unknown.

METHODS

The role of propofol at clinically relevant concentrations in the modulation of radiograph-induced cytotoxicity in HeLa cells transfected with connexin 32 (Cx32) plasmid was explored by manipulation of connexin expression, GJ presence, and function. GJ function, Cx32 protein level, and Cx32 mRNA expression were determined by "Parachute" dye-coupling assay, Western blotting, and reverse transcriptase-polymerase chain reaction, respectively.

RESULTS

Propofol significantly reduced radiograph-induced cytotoxicity only in the presence of functional GJ. Four-hour propofol exposure inhibited GJ function mainly by diminution of Cx32 protein levels but without influence on Cx32 mRNA expression.

CONCLUSIONS

These results suggest that propofol inhibits the function of the GJ through the reduction of Cx32 protein levels by a transcription-independent mechanism. They further indicate that propofol depresses the cytotoxicity of radiograph irradiation through inhibition of GJ activity.